Anesthesia Consent Form

Gives us your permission to safely use anesthesia for your pet’s procedure.

"*" indicates required fields

Client Name*

First Last

Phone*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient Name*

Species*

Sex*

Male

Male (neutered)

Female

Female (neutered)

Color*

Weight*

Anesthetic and surgical procedure(s) to be performed:*

I, the undersigned owner or agent of the pet identified above, authorize the staff of Mayfair Pet Hospital to perform the above procedure(s). I understand that some risks always exist with anesthesia/sedation and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. I give my permission for anesthesia/sedation and/or surgery.*

I do.

I do not.

Cardio Pulmonary Resusitation: I understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life-sustaining procedures. I give permission to perform CPR on my pet.*

I do.

I do not.

Date of Consent*

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow-up radiographs, re-check physical exams, and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. A complete physical exam will be performed on your pet prior to the surgical procedure. However, this may not identify all systemic or metabolic problems. For this reason, your pet will have a pre-anesthetic blood panel to evaluate major organ functions prior to anesthesia. I have read and fully understand the terms and conditions set forth above.

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